Arizona has joined a growing list of states that have adopted a dose of tough love for patients seeking prescription pain pills, but some medical experts question the policy's wisdom.

Gov. Doug Ducey signed an order last month to limit initial painkiller prescriptions to seven days for Arizona adults insured by Medicaid or the state’s health-insurance plan. The Republican governor said he hoped private health insurance plans would adopt similar policies restricting initial prescriptions for highly-addictive opioids such as OxyContin and Vicodin.

Some doctors have said the new plan may be too restrictive and could interfere with physician-patient relationships. But Ducey said action is pivotal to help prevent Arizonans from getting hooked on prescription pain pills amid an opioid epidemic. With 401 Arizona overdose deaths from prescription opioids last year, Ducey said, he believed that he needed to act to curb more overdoses.

“These large prescriptions of highly addictive substances are incredibly dangerous, and we have to take action now,” Ducey said. “By limiting the fills of prescriptions for all state health plans, we hope to encourage private companies to consider similar action.”

An attempt to curb opioid epidemic

Arizona’s Medicaid program provides health insurance to more than 1.9 million Arizona residents, and the state health plan covers more than 135,000 state and university employees and family members.

Arizona adults on Medicaid or the state’s health insurance plan can get a larger refill after a second visit to a doctor. But opiate prescriptions for minors will always be limited to seven days, unless the child has cancer, chronic illness or a traumatic injury.

The one-week limit for Medicaid patients won't begin until the state's Medicaid program, the Arizona Health Care Cost Containment System, drafts new rules and takes comments from the public, said Beth Kohler, the agency's deputy director. She said pharmacy benefits managers need 90 days to enact such a change, so she anticipates the new policy will take effect April 1, 2017.

Arizona policymakers said that targeting consumers before they begin using painkillers is key to prevent opioid addiction, which experts warn can lead to heroin addiction.

The Ducey administration pursued the new restrictions based on a recommendation from the state's substance-abuse task force and in consultation with the Arizona Department of Health Services.

"The governor is very interested in and concerned about the opioid epidemic," said Christina Corieri, Ducey's health policy adviser. "Arizona is the ninth-highest state for drug overdoses. That’s not a top 10 list we want to be on."

Arizona is not alone in efforts to halt the opioid and heroin epidemic, which killed more than 28,000 people across the U.S. in 2014.

In March, the Centers for Disease Control and Prevention issued sweeping guidelines that recommended doctors limit opioid prescriptions for acute pain to a three-day supply. Doctors rarely needed to prescribe a supply of more than seven days, the guidelines said.

Massachusetts enacted a law that limited first fills of pain medications to seven days and included other education and treatment provisions. Connecticut, Maine and New York also adopted state laws that mandated seven-day limits for first fills of pain pills, according to a report from the National Governors Association.

The Ducey administration chose to enact an executive order in state-controlled insurance plans rather than seek legislation that mandates all private insurance plans to adopt similar limits.

Questions of convenience, individual variability

The seven-day limit comes after Ducey signed a pair of bills in March that aim to fight pain-pill diversion and overdose deaths. One bill would allow a pharmacist to dispense the overdose antidote naloxone without a prescription to friends, family members or others who can help someone at risk of an overdose death. The other requires doctors to check and update a database before prescribing to prevent "doctor shopping" by a patient seeking to improperly use or sell opioids.

“Some patients do legitimately need opioids. For chronic users, it is very, very inconvenient to tell them they need to come to the clinic every week to get their prescription filled.”

Dr. Mohab Ibrahim, a University of Arizona College of Medicine professor who directs a pain clinic at Banner University Medical Center in Tucson

But some doctors have questioned whether limiting prescriptions or requiring more frequent refills could create other challenges to the state's strained health system. Typically, doctors already monitor pain-pill patients with expensive urine screens.

“Some patients do legitimately need opioids," said Dr. Mohab Ibrahim, a University of Arizona College of Medicine professor who directs a pain clinic at Banner University Medical Center in Tucson. "For chronic users, it is very, very inconvenient to tell them they need to come to the clinic every week to get their prescription filled."

Ibrahim said his clinic's appointment calendar often is booked three to four months in advance, so it may be difficult for a new patient to get timely access to care. The wait time could lengthen if patients with chronic pain had to return one week after getting a prescription.

While Ibrahim said he likes the idea of discouraging opiate use — he typically only prescribes such powerful pain medication after other pain-relief therapies don't work — he said opiates sometimes may be necessary to treat a patient. He cited the example of a patient following surgery.

"Limiting to seven days may be inconvenient for the patient and the surgeon," Ibrahim said.

Dr. Lynn Webster, an anesthesiologist and past president of the American Academy of Pain Medicine, said such broad-brush policies interfere with the doctor-patient relationship.

"These rules that are being set by politicians are not taking into account the individual variability of patients," said Webster.

'This came out of nowhere … I am terrified'

Chronic-pain patients such as Mesa resident Amy Lay worry that they’ll suffer as government agencies create new guidelines for doctors who prescribe opiates.

Lay, who is insured by Medicaid, has ankylosing spondylitis, an inflammatory disease that has led to severe joint and back pain.

The 37-year-old mother of three has used a combination of two pain drugs for years when non-opioid treatments such as physical therapy, injections and an acupuncture-type treatment failed to curb her pain.

“I am able to function,” Lay said. “It allows me to get up in the morning, take care of the kids and go to work … Now they want me to get off (the pain medication). It is a bit concerning.”

“I guess because of the crackdowns and stuff, they decided they no longer want me on it (pain medication). I don’t have an addictive bone in my body. I don’t smoke, use drugs or drink. I don’t have a history of doing anything illegal. I follow their directions to the T.”

Amy Lay, Mesa chronic-pain patient

During a trip to a pain-management clinic earlier this month, her doctor told her that he wanted to aggressively wean her off her pain medications. The doctor reasoned that she is too young to be on the pain medication that she takes.

The doctor has cut her medication in half and plans to completely wean her off pain pills next month while referring her to a rheumatologist.

Lay feels that she is caught up in the nationwide move to curb opioid treatments.

“I guess because of the crackdowns and stuff, they decided they no longer want me on it (pain medication),” Lay said. “I don’t have an addictive bone in my body. I don’t smoke, use drugs or drink. I don’t have a history of doing anything illegal. I follow their directions to the T."

"This came out of nowhere … I am terrified,” she said.

Others, however, say it's smart policy to try to prevent addiction by targeting new opioid users.

Paul Auchterlonie is CEO of Decision Point Center, a drug- and alcohol-addiction treatment facility with locations in Scottsdale, Prescott and Prescott Valley. He said targeting minors with a perpetual seven-day limit is smart because adolescents are particularly vulnerable to addiction.

However, he said attempts to tighten prescribing methods could create the unintended consequence of people seeking pain pills or heroin on the black market.

Auchterlonie said drug cartels have responded by packaging heroin in pills, rather than in powder or other forms that must be dissolved and injected by a needle. He said the pill form is more palatable for addicts from teens to soccer moms.

"We think heroin and we think about people shooting up needles," Auchterlonie said. "The cartels and drug dealers are quite intelligent with supply and demand."